short and insightful writing about a long and complex history

Medicine or Vacation? Selling addiction treatment, circa last century

If, like me, you’ve spent the past several years studying the history of addiction treatment, then you might know why I can’t look at beachy treatment ads—they tend to resemble the image below— without thinking about the work of William L. White, the prolific addiction professional and historian.

Addiction Ends in Malibu?

White’s book, Slaying the Dragon, is a canonical text on the history of addiction treatment in the United States. While Slaying was written to give addiction professionals a sense of their own history, the book is also an essential starting point for any scholar who first approaches the subject. Early on, White describes the “rise and fall of inebriate homes and asylums.” At the turn of the twentieth century, White writes, “a national network of addiction treatment programs was born, was professionalized, and then disappeared—all within the span of a few decades.” In his analysis of the dissolution of the early addiction treatment industry, White finds parallels with the precarious position of treatment providers today: a motley of institutional models for addiction treatment, conflicting professional interpretations regarding the nature of addiction, and unreliable political support.

One parallel is evident in contemporary treatment ads. While a combination of forces led to the decline of treatment centers a little less than a century ago, one of the most salient factors, it seems to me, was the economics of Gilded Age addiction treatment. Despite significant changes in theories of addiction, drug policy, and treatment trends over the course of the last century, the pitch for ritzy, private treatment centers has remained remarkably faithful to its early rhetoric.

Today’s treatment centers handle an array of addictions—in addition to alcohol and drug dependence, the term “addiction” covers food, sex, and gambling. The first draft for this unified theory of addiction appeared under the diagnostic catch-all inebriety. For the pioneering professionals studying the concept, treatment was wedded to research; The Quarterly Journal of Inebriety struggled to separate treatment fads and ads from rigorous scientific papers (for more on the journal, see Pointshere). Marketing was necessary for professionalization and institutional survival. White argues that centers specifically designated for curing inebriates—whether state asylums or tony, specialized sanitariums—relied more on charismatic leadership than public support. Unlike prisons, orphanages, or even insane asylums, he notes that the new treatment centers had “no central mechanism” or governing body to fund or evaluate them. As a result, some planned state facilities were never financed, while others closed when local coffers ran empty. Private facilities were vulnerable to the whims of the market, as faddish treatments fell out of favor and a series of economic depressions shrunk the pool of potential patients. In the early 1920s, the number of private treatment chains dropped precipitously; by the mid-1920s, most of the prominent franchises had gone out of the addiction treatment business.

Of course, the rise of prohibition and criminalization also contributed to the decline of the early rehab centers; some public facilities were converted to prisons. Even so, the push for prohibition did not entirely eradicate the demand for specialized centers for the substance-dependent sufferers from “respectable” classes. (Timothy Hickman has argued that today’s “double meaning” of addiction— as both an illness and a crime— emerged alongside the initial professionalization of addiction research and treatment in the late nineteenth and early twentieth centuries.)

Although private centers have doubtless relied on coercion to compel clients into treatment, a certain class of patient was also, historically, the target of more subtle forms of persuasion. To attract clients who could afford the new addiction cures, treatment was depicted more like an expensive vacation than a painful process of soul searching, penitence and character-building labor. Whatever the reality, the original pitch for high-class recreational therapy made it look more like a Chautauqua retreat than the moral treatment associated with some insane asylums. For ages, a similar tactic for recruiting clients who could pay full freight for the latest cure has often transcended important differences in actual treatment modalities. Organizations that catered to clients with means combined claims of treatment efficacy with references to recreation, healthy stimulation, and lush surroundings.

In early twentieth century Florida, the Jacksonville branch of the controversial Keeley chain marketed itself as “the only Keeley Institute in Florida.” According to White, the Keeley Institutes (founded in 1879) were the blockbuster treatment franchise of the late nineteenth and early twentieth centuries. The Jacksonville “Keeley Cure” advertisement claimed that its proprietary therapy—which combined daily injections of Keeley’s top-secret “Double Chloride of Gold,” tonics, and mutual aid in a controlled atmosphere—had “cured” more than 400,000 clients of “drunkenness, opium, morphine, and other drug using.” This statistic was probably an exaggeration; White estimated that 500,000 clients—total—took the cure between 1880 and 1920. By the end of the nineteenth century, it was publicly evident that many of these patients relapsed. Even so, the Jacksonville Keeley franchise ad relied on the Institute’s exotic location, not its cure rate, to distinguish it from the other Keeley branches that used the same treatment regimen for businessmen-addicts. (The Nevada Institute similarly billed itself as the only Keeley branch in the state, located “near the base of the Sierra Nevada mountains” in a “climate as nearly perfect as can be found on the American continent,” with “every night a peaceful, restful vacation.”)

Later, when the concept of inebriety began to splinter into substance-based categories like “alcoholism” and “drug addiction,” famous hospitals and sanitariums continued to make a similar sell to elite clientele. According to Susan Cheever, Towns Hospital, located in an opulent Victorian building on Central Park West, catered to the “fashionable and famous” throughout the 1920s and 1930s. Its founder, Charles B. Towns, lobbied in favor of more stringent narcotics control while promoting his belladonna-based hallucinogenic treatment formula (clients were required to pay for the pricey treatment in advance). Towns’s 1930s advertisement does not dwell on the mechanics of the treatment—calling it simply a “regular hospital procedure” that has been “fully described in the Journal of AMA”—and focuses instead on the prestigious address, “openness” of the institution, and facility amenities.

Towns Hospital advertisement (Source: nytimes)

The hospital became best known, however, as the location where Alcoholics Anonymous co-founder Bill Wilson had a spiritual experience that inspired the creation of AA. Towns’ chief of staff, William Silkworth, ultimately became one of AA’s greatest proponents; Towns helped finance Wilson’s draft of AA’s “Big Book.” When Charles Towns offered Wilson a job as a counselor at the hospital, Wilson declined; his growing fellowship wanted to maintain AA’s independence from profit-driven treatment providers like Towns Hospital. But a few decades later, when the AA-influenced “Minnesota Model” had become the dominant paradigm in alcoholism treatment, centers like Hazelden sold it much the same way Towns had. “Rest and freedom from responsibility are important,” touted one ad from the 1950s. “Fishing, pool, and shuffleboard are some of the possible diversions.”

As of last month, Hazelden is negotiating a merger with the Betty Ford Center. First Lady Betty Ford’s struggle with prescription drug and alcohol abuse inspired her center, which became synonymous with high-end treatment and celebrity recovery soon after its debut in 1982 (Liz Taylor, Johnny Cash, Robert Downey Jr, and Lindsay Lohan were all clients). Ford initially resisted lending her name to the center, and later expressed discomfort about the popular tendency to substitute her brand name for the more general concept of addiction treatment. “I wonder why people can’t say, ‘We went through treatment,’” rather than “we went through Betty Ford,” she reportedly griped. But the Betty Ford trademark became part of her national legacy; a recent Smithsonian exhibition featured a Betty Ford Center brochure. Its layout emphasizes the idyllic view of the Rancho Mirage, California grounds over the Fords’ optimistic endorsement of the treatment approach. The same landscape is featured on the Center’s Facebook page today.

While treatment science and regulation have improved since the beginning of last century, for a privileged few the decision about where to go for drug treatment is still not entirely a rational calculation; it’s partly a matter of taste. For example, the Passages Malibu website describes its model as anti-AA, a market alternative for clients put off by the twelve step rhetoric associated with other treatment centers—but the site offers scant data about the efficacy of the recreational therapies that Passages provides.

The persistent representation of addiction treatment as a kind of luxury item is troubling for several reasons. Historically, advertising rhetoric has not always matched the reality of treatment. Historian Sarah Tracy noted that the private inebriate asylums of the mid-nineteenth century may have pulled off a bait-and-switch pitch, selling therapeutic activities such as “billiards, rowing, diving, and horseback riding” but privately subjecting patients to the standard of care at the time: discipline and confinement.

Also—just as Betty Ford intuited— I haven’t found much evidence that good marketing for individual, private treatment providers necessarily translates into increased public awareness about the importance of treatment in general. I worry that extravagant advertisements and high-profile relapses might do the reverse: reinforce the stereotype that addicts are inherently irresponsible, indulgent and escapist. That stereotype, of course, does the most damage to people who will never have the option to seek treatment on a beach.